OIG and CMS Tout Recent Enforcement Successes and the Pivotal Role of Data Analytics
In recent reports, both the U.S. Department of Health and Human Services’ Office of Inspector General (OIG) and the Centers for Medicare and Medicaid Services (CMS) plugged their successes at routing out fraud and abuse involving federal reimbursement programs and preventing improper Medicare payments. A common theme emerging from the OIG and CMS updates is that data analytics have been critical to these successes. OIG Semiannual Report The OIG touted its efforts and achievements for the six-month period ending March 31, 2016—that is, the first half of the fiscal year 2016—in its most recent Semiannual Report to Congress released May 31, 2016. The OIG is required by law to semiannually report to Congress about significant findings and recommendations. This latest report cites the following enforcement results: $2.77 billion in recoveries ($554.7 audit receivables, $336.6 non-HHS investigative receivables such as Medicaid restitution) 428 criminal actions against individuals and entities 338 civil actions such as False Claims cases and Civil Monetary Penalties settlements and self-disclosure program recoveries 1,662 exclusions from federal health care programs Strike Force efforts yielding 87 individuals and entities charged, 100 criminal actions and $116.8 million in investigative receivables This year’s report also spotlighted OIG guidance for the industry […]
In recent reports, both the U.S. Department of Health and Human Services’ Office of Inspector General (OIG) and the Centers for Medicare and Medicaid Services (CMS) plugged their successes at routing out fraud and abuse involving federal reimbursement programs and preventing improper Medicare payments. A common theme emerging from the OIG and CMS updates is that data analytics have been critical to these successes.
OIG Semiannual Report
The OIG touted its efforts and achievements for the six-month period ending March 31, 2016—that is, the first half of the fiscal year 2016—in its most recent Semiannual Report to Congress released May 31, 2016. The OIG is required by law to semiannually report to Congress about significant findings and recommendations.
This latest report cites the following enforcement results:
- $2.77 billion in recoveries ($554.7 audit receivables, $336.6 non-HHS investigative receivables such as Medicaid restitution)
- 428 criminal actions against individuals and entities
- 338 civil actions such as False Claims cases and Civil Monetary Penalties settlements and self-disclosure program recoveries
- 1,662 exclusions from federal health care programs
- Strike Force efforts yielding 87 individuals and entities charged, 100 criminal actions and $116.8 million in investigative receivables
This year’s report also spotlighted OIG guidance for the industry released in the first half of the fiscal year. Guidance relevant to the laboratory sector included an OIG policy reminder about information blocking—which is critical to achieving interoperability and facilitates coordination of health care services.
The OIG asserted in this latest report that “CMP recoveries have increased almost five fold over the past 3 years, and the OIG is on track to exceed prior recoveries in FY 2016.” Last year’s semiannual report predicted the OIG would recover more than $1.8 billion from investigations and enforcement actions for the first half of fiscal year 2015 and reported 422 criminal actions and 320 civil actions involving health care compliance issues. Yet, the agency did see declines from some of last year’s achievements. Exclusions for the first half of 2015 were 1,735 and Strike Force was credited with yielding $163 million, and 124 criminal actions. See “OIG Enforcement for First Half of Fiscal 2015 Expected to Yield $1.8 Billion in Recoveries,” National Intelligence Report, 6/11/15, p. 5.
| OIG Podcast Explains Value of Data Analytics to Enforcement Efforts |
The Office of Inspector General’s (OIG’s) latest podcast posted June 7, 2016, features an interview with Caryl Brzymialkiewicz, the Chief Data Officer for the OIG, who explains the value of data analytics to the agency’s investigative and enforcement efforts. Bryzmialkiewicz explained that the Chief Data Office, which was initiated a year ago, is charged with “providing more and better access to data and analytics to support OIG’s mission” and has three functions:
She added that her office is focused on “how do we help the OIG become even more effective and efficient in what it’s doing—which includes improving our access to data”— by determining what datasets are needed and how to ensure high quality data. One strategy employed to utilize data to fuel investigations and enforcement is actionable advanced analytics which Brzymialkiewicz describes as “high quality lead-generation” for OIG investigators, auditors and evaluators. “One of two things can happen with our advanced analytics. Either the data can lead us to somebody that is potentially committing fraudulent activity or our investigators can have a hotline call where they can have a witness or a whistleblower come tell them that they suspect criminal activities happening, and we can bounce that against the data. So it’s a really a combination of the data analytics and the data scientists and our statisticians and computer programmers with that field intelligence of our law enforcement agents working in the field—that combination is very powerful,” she explained. The work of the Chief Data Office also allows the OIG to use parameters set using statistical methods to identify high risk providers who will receive closer scrutiny. The office is considering new ways to “democratize data” and make the information gleaned from analytics more useful throughout the OIG. For example, Brzymialkiewicz discussed the ability to plot data geographically to reveal compliance hotspots in the country where fraudulent activity may be happening or an audit or evaluation may be warranted. Another tool the office uses is the peer comparison generator that helps spot providers who are outliers and identify trends. Link analysis is a strategy the agency uses to draw connections among providers. “What I’m really thinking about as well, now that we’re going from fee-for-service to value-based care, inherently there are connections between organizations. A lot of them are very good. So when we’re trying to find the people that are potentially committing fraud, waste and abuse, how do we need to think about our data in different way— or how do we need to bring a different approach to that problem to see and understand where we might need to look, even further,” she explains. The information revealed through analytics helps the agency internally as well to inform decision makers when setting priorities and allocating resources and staffing. “[T]hen if we need additional resources, we’re standing on some very solid ground in terms of our logic of what we need when we go back and ask people for additional money,” added Brzymialkiewicz. |
Enforcement cases highlighted within the report included sentencing of another individual in the Biodiagnostic Laboratory Services case. So far, 20 individuals have been sentenced according to the OIG for an aggregate of 41 years of prison.
The case has also yielded $487,250 in fines and $510,695 in forfeiture and 15 exclusions for an aggregate of 111 years. The OIG also highlighted the Millennium Health $256 million False Claims Act settlement resolving allegations of medically unnecessary drug testing and genetic testing, and kickbacks to referring physicians.
In Inspector General Daniel R. Levinson’s introductory message to the report, he notes the “OIG leverages technology and forensic audit techniques to identify and address emerging fraud trends and to support efforts to deter misconduct through administrative actions. OIG investigations, including work on Strike Force cases, target emerging patterns of fraud and help to hold wrongdoers accountable.” Utilizing data for enforcement purposes was similarly the focus of the CMS report on its enforcement successes.
Medicare Fraud Prevention System
Just as the OIG emphasized the benefit of using data and technology as enforcement tools, CMS claimed using Big Data in its enforcement and oversight efforts has yielded big savings for Medicare. CMS asserted its Fraud Prevention System (FPS) has identified $1.5 billion in inappropriate payments “through new leads or contributions to existing investigations.”
In a recent issue of The CMS Blog, the agency explained the FPS uses big data and predictive analytics to proactively ferret out fraud and abuse and prevent improper payments from happening: “Taking ‘big data’ mainstream has given CMS the ability to better connect with public and private predictive analytics experts and data scientists, as well as collaborate more closely with law enforcement. The Fraud Prevention System’s ‘big data’ effort has had a profound impact on fraudulent providers and illegitimate payments by allowing us to quickly identify issues and take action.”
CMS claims that FPS streams 4.5 million prepaid claims daily and yielded a $11.60 return on investment in 2015 for each dollar spent on the system, recovering $1 billion in savings between 2013-2015. CMS also promises continued focus on use of analytics to fight fraud: “The CMS is now working to develop next-generation predictive analytics with a new system design that even further improves the usability and efficiency of the FPS.”
Takeaway: Federal government enforcement efforts are unrelenting, with data and technology serving as tools to ferret out fraud and other improper Medicare claims.
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